Provider Demographics
NPI:1225389067
Name:MILLER, NICOLE STACI (MS CCC SLP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:STACI
Last Name:MILLER
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 TRAVIS AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6129
Mailing Address - Country:US
Mailing Address - Phone:917-856-3773
Mailing Address - Fax:
Practice Address - Street 1:328 TRAVIS AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6129
Practice Address - Country:US
Practice Address - Phone:917-856-3773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023005235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist